Dr. Marc Avram

The Fraxel Laser: Effective Treatment for Sun Spots

Fraxel employs a technology called non ablative fractional resurfacing. It is non ablative becausethe epidermis, the top layer of the skin, remains intact after Fraxel treatment. Fraxel ablative lasersurgery is in between the initial resurfacing that was done with CO2 ablative resurfacing, which washighly successful to treat aging skin, acne scarring, and rejuvenate the skin but did create prolongedredness and had an increased risk of discoloration and scarring in the skin. On the opposite end of laserrejuvenation is non ablative, non fractional laser rejuvenation. It is effective for treating aging skin andacne scarring with minimal to no redness or down time.
Fractional ablative, otherwise known as Fraxel laser, is technologically somewhere in between. It worksby firing high energy pulses deep into the skin but leaving the top layer of the skin intact. This makes theprocedure safe. The deep firing of laser light through the skin does cause redness that lasts on averagetwo to four days as opposed to weeks with CO2 ablative laser.
Fractional ablative resurfacing is most effective for treating background sun damage. Background sundamage is the brown mottling and roughening that occurs of the skin with chronic sun exposure. Fordiscrete large freckles that occur with aging of the skin, Q-switch lasers, which are performed in ouroffice as well, are most effective and often we combine fractional resurfacing with Q-switch lasers forthe maximum improvement for our patients.
In addition to treating sun damage, fractional lasers are highly effective to treat acne scarring andsurgical scars. A series of treatments results in an improvement in scars. Currently fractional resurfacingtechnology is thought to be the safest and most effective treatment for improving scars.
When the fraxel was first released it was thought to be a miraculous treatment for melasma. Melasmais related to a combination of sun damage and hormones that causes pigmentation on the cheeks, upperlip, forehead, and chin in any combination, usually more prominent in the summer months after sunexposure. Initial reports with fraxel were encouraging that it did seem to have long term improvement.However, with subsequent, it has become clear now that melasma does recur and fraxel currentlyremains a tertiary, not primary treatment, for melasma. We do have good treatments including topicalcreams and chemical peels to improve it but there is no cure for it.
How is fraxel done?
Fraxel is performed as an outpatient using a topical anesthetic cream. The treatment takesapproximately twenty to forty minutes. After the procedure a moisturizing cream is applied. There isusually no associated pain after the procedure. Wound care entails keeping the skin well moisturizedfor two to three days. Patients are able to wear make-up after the procedure. Most patients resumenormal activities immediately. There is background redness that looks like sunburn. After three tofour days the redness fades to the point that patients are able to resume full regular social and physicalactivities.
How many treatments?
Typically, the patient undergoes two to four treatments.
How safe is it?
Fraxel is a safe laser treatment but as with any treatment there is a possibility for side effects. Sideeffects can be minimized but not eliminated by having Fraxel done by an experienced laser surgeon withappropriate energy settings.

Finasteride – Effective In Treating Earlier Stages of Hair Loss in Men

Finasteride has been approved by the FDA for male pattern hair loss since 1997.  It is NOT approved for female pattern hair loss and should not be used by women in child bearing years.  Finasteride has no allergic reactions, no drug interactions, nor required blood test monitoring.  Over fifteen years of clinical experience the vast majority of patients who have used it have benefited from it with no side effects.  It is most effective at earlier stages of hair loss where there is still ample pigmented terminal hair as opposed to fine thin wispy hair follicles that arise at later stages of male pattern hair loss.  Patients with more advanced hair loss, with less hair on their scalp, do not typically benefit from the medication.

Propecia has been approved only for male pattern hair loss. If a woman takes it and gets pregnant it will cause birth defects.  It was specifically studied by the FDA before approval as to whether or not it affected sperm or had any increased risk for men on the medication getting a woman pregnant and the data showed it to be safe.  Over the years, some patients have been concerned about whether or not they should be on it while starting a family or have difficulty getting their partner pregnant.  I have counseled patients that if they are concerned at all with the medication they should not use it.  The data shows it to be safe, but if there is any concern avoid any added stress.  

More recently, there have been reports of permanent sexual side effects.  The clinical trials done in the early to mid 1990’s failed to reveal this as a side effect and, in my clinical experience over the past fifteen years, no patient that I am aware of has complained of permanent sexual side effects from it.  There are a small percentage of men that do get sexual side effects, all of which have reversed when they discontinued it.   The current scientific consensus is that there is no increased risk of permanent sexual side effects but the only way to resolve the matter is to have a well designed, long-term, clinical trial, to separate Propecia-induced sexual side effects vs. a small percentage of men that have sexual dysfunction with or without using Propecia.  Unfortunately, to get the answer to this question will be many years.  Currently, I advise patients that if they are concerned at all about the risks of the medication, not to use it and to consider using topical minoxidil as a substitute.  For those who feel comfortable, I continue to feel comfortable prescribing the medication based on the scientific data I have seen.  

Another area of concern has been whether or not this medication promotes or helps reduce the risk of prostate cancer.  This has been an issue of great interest in medicine beyond physicians treating hair loss.  Large, multi-central clinical trials were performed and data has arisen from long term well designed trials.  The incidence of prostate cancer on patients using 5 mg of finasteride was reduced.  The only problem is a small increase in more aggressive type prostate cancer in this patient population.  The FDA decided to not recommend it to help reduce the incidence of prostate cancer. It is still FDA approved for enlarged prostate treatment and male pattern hair loss. The FDA added a warning to the package for an increased risk of a more aggressive type of prostate cancer in a small percentage of patients.

Attached is a handout that a colleague of mind, Dr. Dow Stough, from Hot Springs Arkansas has created for his patients regarding Propecia.  I have attached it to the blog to give you further information about the finasteride.

In summary, I believe finasteride is a highly effective medication for men at earlier stages of male pattern hair loss.  It seems to continue to work over many years for patients without side effects.  If you are concerned about using it for any reason I advise using topical minoxidil.  

Download Dr. Dow Stough's Hand Out

 

Check out Dr. Avram discussing the latest options in hair transplantation surgery with Bloomberg TV!

http://www.bloomberg.com/video/89289593/

An article from the Journal of the American Academy of Dermatology (JAAD) Volume 65, Number 6:

 

A randomized, single-blind trial of 5% minoxidil foam

once daily versus 2% minoxidil solution twice daily in

the treatment of androgenetic alopecia in women

 

Ulrik Blume-Peytavi,MD, PHD, Kathrin Hillmann, MD, Ekkehart Dietz, PHD, Douglas Canfield,

and Natalie Garcia Bartels, MD

Berlin, Germany and Fairfield, New Jersey

 

Background: Although twice-daily application of propylene glycol- containing 2% minoxidil topical solution (MTS) stimulates new hair growth, higher concentrations of minoxidil in a once-daily, propylene glycol-free formulation may improve efficacy and reduce unpleasant side effects.

Objective: WE sought to compare the efficacy, safety and acceptability and to show noninferiority of once-daily 5% minoxidil topical foam (MTF) with twice-daily 2% MTS in woman with androgenetic alopecia.

Methods: A total of 113 women with androgenetic alopecia were randomized to 24 weeks of treatment with 5 % MTF and 2% MTS. The primary efficacy parameter was change from baseline in nonvellus target area hair count at week 24. Secondary end points included change in nonvellus target hair width, overall efficacy by global photographic review as assessed by treatment-blind evaluators and the subject herself, adverse events and participants’ assessment of product aesthetics.

Results: After 24 weeks, women randomized to 5 % MTF once-daily showed noninferior target area hair count and target area width and experienced great, but nonsignificant , improvements in target area hair count, target area hair width and overall efficacy by global photographic review than those randomized to 2% MTS used twice-daily. 5% MTF was significantly superior to 2% MTS in participants’ agreement with “the treatment doesn’t not interfere with styling my hair” (P=.002). Women randomized to 5% MTF experienced significantly lower rates of local intolerance (P=.046) especially in pruritus and dandruff with 2% MTS.

Limitation: Because of differences in the formulations tested, study participants were not blinded to treatment.

Conclusions: Once-daily 5% MTF is noninferior and as effective for stimulated hair growth as twice-daily 2% MTS in women with androgenetic alopecia and is associated with several aesthetic and practical advantages. (J Am Acad Dermatol 2011;65:1126-34.)

Key words: androgenetic alopecia; female pattern hair loss; hair preparations; hypertrichosis; minoxidil; topical administration; topical foam; topical solution. 

 

INTERNATIONAL SOCIETY OF HAIR RESTORATION SURGERY MAINTAINS SAFETY AND EFFICACY OF PROPECIA
(FINASTERIDE 1MG) FOR MALE HAIR LOSS IS BACKED BY PROVEN SCIENTIFIC DATA
Task force formed to study reports of sexual dysfunction in some men taking Propecia for hair loss
GENEVA, IL. – December 13, 2011. The International Society of Hair Restoration Surgery (ISHRS) – the world’s leading medical authority on hair loss and hair restoration – cautions that recent anecdotal reports of persistent sexual dysfunction by some men who have used finasteride 1mg (Propecia) to treat hair loss should not define the safety and effectiveness of this drug. Propecia is the only oral medication approved by the U.S. Food and Drug Administration (FDA) for the treatment of hair loss in men.
From a scientific standpoint, the ISHRS reports that there are no evidence-based data substantiating the link between finasteride and persistent sexual side effects after discontinued use of the drug in numerous, double blinded, placebo controlled studies conducted evaluating the use of Propecia 1mg for hair loss.

“The health and well being of our patients is the utmost concern of the 900 physician members of the ISHRS – whether prescribing medications like Propecia or performing hair restoration surgery,” said ISHRS President Dr. Jennifer Martinick. “ISHRS members devote an average of 72% of their practices to medically and surgically treating hair loss, and collectively they have treated millions of men around the world suffering from hair loss with finasteride 1mg with virtually no side effects.”
Since receiving FDA approval in December of 1997, 20.5 million and 6.7 million patient-years of exposure using Proscar (finasteride 5mg) and Propecia (finasteride 1mg) respectively are recorded with a low adverse event profile. The ISHRS believes that these are the most current and reliable data available until further studies are conducted.
Sexual dysfunction is a complex disorder, and Dr. Martinick noted that it often can be hard to pinpoint the exact cause – particularly when multiple factors such as nicotine, alcohol, prescription medications, stress, anxiety, fatigue and depression can contribute to erectile dysfunction (ED).
“The incidence of ED in the general population is known to be quite high – as high as 49% in middle-aged and older men according to one study published in 2006 in the Archives of Internal Medicine,” said Dr. Martinick. “That being said, we owe it to our patients to address valid concerns in a scientific manner and to clarify any misleading reports so that men can make informed choices regarding the use of this medication.”
Recently, the ISHRS formed a task force to more closely examine anecdotal reports of sexual dysfunction by some Propecia users who have used the drug to treat hair loss. In addition, the ISHRS has called on the medical communities of dermatologists, hair loss physicians, urologists, endocrinologists and sexual medicine specialists to join in a colloquium to share all data and experiences with finasteride in a fact-based manner.

Robotic Follicular Unit Extraction in the Donor Area.

Over the past several years, an increasingly popular option for removing donor hair from the posterior scalp is follicular unit extraction. Follicular unit extraction is where a 1 mm punch biopsy is utilized to harvest individual follicular units from the donor area. The advantage of this technique is that the small incision made to remove the donor hair allows hundreds of hair follicles be removed with minimal or no visible detected donor scar on the posterior scalp.

For many patients, a scar on the posterior scalp is of no cosmetic, functional, or practical concern and therefore an ellipse is performed. For other patients that like to wear their hair short, or may want to wear their hair short in the future or who prefer for psychological reasons not to have a donor scar, follicular unit extraction is appealing.

The chief disadvantage of follicular unit extraction is the increased time it takes to remove the hair and less hair that is harvested during each procedure compared to a donor ellipse. Recently, a robotic device has been developed by a company in Silicon Valley named Restoration Robotics. This device may offer an opportunity to harvest large numbers of follicular groupings that will be comparable in number to what can be attained with a donor ellipse. This is a potentially significant advancement in hair restoration surgery since it will allow the best of both worlds; a large number of follicular groupings from each surgery with no visible scar in the donor area. Further experience over the next several months will better define the role of the robot in hair restoration surgery.

Corrective Hair Transplant Surgery After Hair Loss Due to Facelifts and Endoscopic Brow Lifts.

A small percentage of patients undergoing facelift or forehead lift procedures will lose hair along their hairline. The vast majority of patients who do lose their hair after surgery have it re-grow within six to twelve months with no further medical intervention. For some patients, unfortunately, hair does not grow and this becomes a cosmetic concern. The chief complaint is the inability to wear one’s hair back in a pony tail, which leads to limited hair styling options and a woman being self conscious about her appearance.

A large number of one to three hair follicular groupings can help restore a natural hairline if placed by a skilled team at the correct angle. Success in the procedure is judged by a patient’s ability to wear her hair back and not feel self conscious.

In addition to correcting hair loss due to face lifts and forehead lifts, transplantation is also used for patients that have lost hair from either traumatic injuries and/or removal of benign and cancerous tissues in the scalp.

Update on Hair Cloning

Over the past several years, there has been great public interest regarding the possibility of being able to clone our own hair follicles. Current methods in hair transplantation allow consistently natural appearing transplanted hair for men and women. The majority of patients have ample donor hair from the back of their scalp to make a substantial natural cosmetic impact in thinning areas of the scalp. A small minority of patients do not have adequate donor hair and therefore cannot benefit from transplantation. For these patients, cloning hair follicles will be a significant breakthrough in restoring natural growing hair to their scalp. Cloning of hair follicles will not improve the current aesthetic result of a hair transplant but will allow millions more women and men to benefit from the procedure.

Currently, there are several independent, well funded groups investigating cloning. They have made substantial progress but, to date, cloning remains unavailable to patients. It is anticipated it will be several years before it is cloning is available to patients.

Laser Hair Removal

Laser hair removal is highly effective in permanently removing unwanted  pigmented  hair follicles.  All skin types are candidates for laser hair removal.  Thicker hair follicles respond better than fine or thin follicles.  All patients on average require five to eight treatments for a 60 to 80 percent permanent reduction in hair follicles.  The vast majority of patients see a substantial improvement and are happy with the treatment after five to eight treatments. In a small percentage of patients, less hair is reduced after multiple treatments.  The reason for failure is unknown.  Typically, if a patient does not see some improvement after two to three improvements with a laser , we try an alternate laser hair removal device in our office. 

The overwhelming number of patients have no side effects with laser hair removal.  As with all laser devices side effects can occur.  The most common ones include – increased  pigmentation( hyperpigmentation), loss of pigmentation (hypopigmentation), scarring, and infection.  Risk of side effects can be reduced by using the appropriate laser for a patient’s skin type, energy, pulse duration, and technique . 

In summary, laser hair removal is a highly effective treatment for removal of unwanted pigmented terminal hair follicles.  Currently, there are no lasers that permanently remove unwanted gray, blonde, or red hair follicles.  The patient satisfaction is high; the treatment is safe with low risk of side effects, which can be minimized with appropriate laser and candidate selection. 

Frontal Fibrosing Alopecia

Frontal Fibrosing Alopecia